A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature.
Restrain the infant's wrists.
Place the infant in a prone position.
Gently clean the suture line with povidone-iodine solution.
The Correct Answer is A
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Insert the tip of the thermometer 5 cm (2 in) into the rectum. The correct insertion depth is 2.5 cm (1 inch) for toddlers to avoid rectal injury.
B. Place the child in prone position. The child should be placed in the side-lying or supine position with legs flexed.
C. Stabilize the thermometer at the distal end. Stabilizing the thermometer ensures it remains in position during the procedure, minimizing risk of injury.
D. Direct the tip of the thermometer toward the spine during insertion. The thermometer should be directed toward the umbilicus to follow the natural rectal curve.
Correct Answer is C
Explanation
A. Educate the infant's caregiver about the feeding: While important, education should occur after ensuring the prescription is correct.
B. Flush the feeding tube before the feeding: This ensures patency but should only be done after verifying the prescription.
C. Clarify the feeding prescription with the provider. Bolus feedings are typically contraindicated with nasojejunal tubes because the jejunum cannot handle large volumes at once. Continuous feedings are usually prescribed. The prescription should be clarified before proceeding.
D. Place a label on the feeding bag and tubing: Labeling is necessary for safety but is not the priority when the prescription may be inappropriate.
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